Integrated Medicine — A Way to Bring Creativity Back to Medicine?
Introduction
I shall start by asking some questions. As I do so, I am reminded of the great
philosopher, Isaiah Berlin, who said “never ask a question to which you know the
answer”.
I shall simply ask my questions, and at the end I shall come back to them and explore
their relevance to the new Society which we are inaugurating today.
Firstly, why do some many people spend their money on complementary and
alternative medicine (CAM)?
This isn’t public money, its all of us spending our taxed money on treatments that we
must find helpful. The amount of spending is huge, £1.6 billion as estimated by a
BBC Survey carried out in 1998. By comparison, the annual NHS budget is £50
billion. In the USA studies suggest there has been 47.3% increase over a 5 year
period in visits to complementary practitioners with out of pocket expenditure
estimated at $27 billion in 1997 (Eisenberg DM, Davis RB, Ettner SL et al, Trends in
Alternative Medicine in the United States, in 1990 — 1997: Results of the Follow Up
National Survey. General of the American Association, 280,1569-75 1998).
Why do we do it?
It isn’t a case of primitive people indulging in Voodoo, but many within orthodox
medicine would think it is. The people who opt to spend this kind of money are in the
earning part of society, and also in the educated part. So, what is their motivation?
I shall leave this question for the moment.
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Why is there a yawning gap between the evidence base of CAM, and the extent of its
use by an increasing number of the populous?
Why do so many randomised controlled studies of various CAM disciplines turn in
negative results?
The centre of my argument is both an idea and a person, and I am going to talk about
Dr David Horrobin. I am nothing more than a country doctor who likes to think,
perhaps too much for my own good. However, I could not say that of David
Horrobin, he was a leading medical researcher of our time, who sadly died in April of
this year. He published some 800 research papers. What did Horrobin think about
the current state of medical research? Do they get a clean bill of health from
them?
In Horrobin’s own words, published in February this year “we have” he wrote “an
almost wholly reductionist medical community”. He goes on to say that the bio-
medical community “repeatedly makes exaggerated claims about how it is going to
revolutionise medical treatment, in which it repeatedly fails to achieve anything”.
So my keyword is reductionism.
My third and final question is, what is the most challenging aspect of complementary
medicine?
Medical Attitudes to CAM
The Medical Profession is divided as to whether the accelerating trend towards CAM
is positive or negative trend. Those who regard it as negative consider that much of
complementary medicine is connected with superstition and empiricism, and that
modern medicine has been moving away from this for the past hundred years in the
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direction of rationality and evidence. Some would argue that the increasing
popularity of CAM is a return to pre-scientific views and long abandoned healing
traditions. They would interpret the continued rise of CAM as being due to a loss of
nerve of modern medicine. They see this as due to a crisis of confidence in scientific
medicine, and a wider crisis of authority in society and popular disillusion of scientific
expertise in general. The loss of nerve in modern medicine is described in a masterful
fashion in James LeFanu’s book ‘The Rise and Fall of Modern Medicine’, (Abacus,
1999).
Complementary Medicine
Complementary Medicine is characterised by a wide range of opinion and practice,
ranging from practitioners who are almost obsessively devoted to the idea that
complementary and alternative medicine should replace orthodox medicine, and see
orthodox medicine as being bad, harmful, full of risk and only focusing on treating
patient’s symptoms. At the other end of the spectrum, are physicians who are
trained in a range of complementary medical disciplines, who use these in an eclectic
fashion and attempt to integrate these in the best possible way with orthodox
approaches, to the perceived best benefit of the patient. It is this movement that we
are principally concerned with in our fledgling society, the British Society of
Integrated Medicine.
The time of the doctor/complementary physician solely using one therapy, such as
being a homeopath, an acupuncturist or whatever, is now beginning to slowly
disappear. Largely, through increasing understanding of the limitations of what each
therapy can offer and some knowledge of the alternatives that exist to their
particular therapy. In that sense, much of complementary medicine is not holistic,
but has regularly made the claim over many years that it is, with little evidence base
to back this claim.
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This is reflected in a practical sense, in relationship to the lack of success, of a whole
range of initiatives which have encouraged complementary practitioners, and doctors
practising single complementary therapies such as homeopaths to be more willing to
refer their patient to another practitioner who might be able to help a patient better
than they can, rather than for example, in homeopathy, eternally searching for the
similimum. The trend of doctors to become multi disciplinary is a welcome and
practical move away from this therapy dominated CAM culture.
A group of patients has grown up, with doctrinaire attitudes towards complementary
medicine, and in extreme cases, resolutely refusing to have anything to do with
conventional medicine. This was brought home to me some few years ago when I read
of a diabetic child, whose parents refused to let the child have insulin, and insisted
that the child should be treated by ‘natural’ methods. Not surprisingly the child died.
These type of patients are given short shrift by conventional doctors and doctors
with an integrated approach certainly find them challenging.
Complementary and alternative medicine has found it difficult to respond to the
current scientific climate in medicine. Partly in my view, due to the fact that most of
the disciplines within complementary medicine are traditional disciplines such as
traditional Chinese medicine, Ayurvedic medicine and homeopathy. Inevitably, if a
system is traditional it is also relatively static and unchanging. From a scientific
point of view this is a weakness, although supporters of these systems of medicine
generally make a virtue of the fixed nature of the ideas underpinning these disciplines.
In many instances this can verge on a religiose attitude, most commonly in relation
to homoeopathy. Some make wild claims that homeopathy will enable its recipients
to reach a state of continuous and unconditional happiness! (G Vithoulkas, The
Science of Homeopathy 1980).
Research in Complementary and Alternative Medicine
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Conventional medical research defines randomised controlled trials as the gold
standard. In these trials patients are randomised either to a treatment group or to
a placebo group. The results of these studies are considered to be the peak of
academic excellence. Criticism of this holy cow is rarely tolerated and can brand the
author of the critique as a medical heretic.
Within the field of complementary medicine research, it has to be said, that the
results of randomised control studies are often negative and do not support the
extent of use of complementary therapies by the general population in increasing
numbers throughout the world. Indeed the disparity is a yawning gap. In my view
there must be some reason as to why this is the case.
I venture to suggest that the use of randomised controlled studies is not an
effective way of assessing the efficacy of a whole range of complementary medicine
disciplines. In my view, the use of non-randomised matched cohort studies, and this
is essentially an observational outcome study design, is the most viable option.
What this means is taking a group of patients with any particular condition, so that
the choice of patients for the study is not randomised. The total group of patients
being studied is known as a cohort, and the matching is against a similar group
matched in relationship to type of disease, severity of disease, age and sex. This
group would not be receiving the treatment being studied, and in cancer, could come
from comprehensive databases which are available with this information. The
problems with these kinds of studies, is that practically all the main stream journals
will not publish them, so one has to be content with publication in less important
journals.
In a matched cohort study, the goal is to identify a control group of patients similar
in all relevant ways to the study or intervention group. Matching of cases is
undertaken on factors such as age and severity of disease, or problem at the base
line, plus any other factors thought to be influenced on the outcome. Done well these
studies can provide valuable information about the relative effectiveness of various
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interventions. However, the problem is that it may be hard to match for all factors.
Any unaccounted for factors, due to ignorance of the mechanism of action of any
particular intervention, if for example, they remain differentially distributed in the
compared groups, they may create systematic differences in the outcomes. This
means that there is increased uncertainty about whether the results are due to the
treatment or to the uneven distribution of the unmatched characteristics. This
problem may reduce, if these unknown factors are randomly distributed, if the group
sizes are sufficiently large.
One well known study which was just such a study, as described, was the study on
the survival of patients with breast cancer attending the Bristol Cancer Help Centre
(Bagenal et al, 1990, Survival of Patients with Breast Cancer Attending the Bristol
Cancer Help Centre. Lancet 336:606-10).
This study became well known because of the negative conclusions regarding the
impact of the Bristol Cancer Help Centre attendance and received a great deal of
media attention. Essentially this showed that the patients attending the Bristol
Cancer Help Centre faired significantly worse than those who did not. The matching
however, between those who attended the Bristol Cancer Help Centre and the
controls, was shown to be defective and as a result the authors, following a public
debate about the study design, formally withdrew the main conclusions from the
study. This resulted in a tragic outcome for one of the authors. In my own
integrated medicine practice, we now have a peer reviewed study protocol for an
observational outcome study of our cancer patients over a three year period. One of
our peer reviewers, a well known professor of oncology, pointed out that in order to
find matched controls in a similar study which he had conducted, took him over two
years. So, this is a major area of possible fault with these kind of studies.
Reductionism does have its place, and being able to reduce a condition down to a
particular bio-chemical disorder and then correct that, can lead to the cure of that
disorder. This approach has worked admirably in a whole range of medical conditions.
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Obvious examples of this would be the use of insulin in type 1 diabetes, or the use of
antibiotics in bacterial infections. On the other side of the coin, complex common
debilitating conditions such as Chronic Fatigue Syndrome to name but one, tend not
to respond to single hit approaches. So, all is well and good for simple conditions,
but not for complex conditions which form the majority of illnesses for which patients
consulting complementary therapists and integrated medicine doctors comprise.
Large Clinical Trials in Rapidly Lethal Diseases
This is an area that particularly interests me, as treatment of cancer, mostly in its
late stages, is an important part of our clinical practice. In this section I wish to
draw extensively on David Horrobin’s paper ‘Are Large Clinical Trials in Rapidly Lethal
Diseases Usually Unethical? (Lancet 2003; 361: 695-97). This section will also talk
about the use of integrated approaches in cancer.
There is much prejudice and ignorance surrounding the use of complementary
approaches in cancer. Many of these approaches are under researched, but in many
cases there is some degree of research backing published in peer reviewed journals
and these approaches have produced encouraging results in a range of cancer
patients. We see many cancer patients and because our evidence base is limited
compared to conventional approaches to cancer, we mostly see stage 4 cancers as
the current evidence base strongly supports conventional approaches at earlier
stages of cancer. This is why our treatments are only available on an informed
consent basis. Occasionally patients at an earlier stage of the disease process
come to see us. Because there is a strong evidence base for conventional treatment
strategies, this does not mean that other treatment might not also work just as
well. Amongst the group who come to see us at an earlier stage of the disease
process, are doctors, which is indeed curious, but an interesting fact. Oddly enough,
they wish to remain incognito so far as their conventional colleagues are concerned.
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David Horrobin died from mantle cell lymphoma in April 2003, in his sixty-third year.
He was a great loss to medicine and had a wonderfully creative mind. He was a
prestigious medical researcher who has written over 800 papers over the past forty
years. Some two years ago he was diagnosed as having advanced mantle cell
lymphoma and was given a prognosis of six months. In his own words, he suddenly
found himself on the other side of the divide, no longer a doctor, but a patient. He
started to look at clinical trials in a completely different way. His change in mind set
parallels the change in mind set in the doctors who come to consult us with cancer,
who themselves have had extensive experience in treating cancers of their patients.
Horrobin devised his own non-toxic treatment of his lymphoma and in the end
survived nearly two years (A low toxicity maintenance regime, using eicosapentaenoic
acid and readily available drugs, for mantle cell lymphoma and other malignancies
with excess cyclin D1 levels, by Horrobin D in medical hypotheses 2003 60(5)615-
623.)
Horrobin extensively reviewed the literature on the treatment of cancer. He says the
following:
‘To my dismay, I soon learnt that in oncology, with few exceptions, effect sizes were
very small. To show these effects, trials had to be very large. I also learned from my
fellow patients that the real consequences of this situation were rarely spelt out to
those volunteering for such trials, in terms they could understand. I thought long
and hard about this situation and came to the conclusion that, as presently
organised, many oncology trials are unethical. Similar considerations apply to any
other rapidly lethal disease’.
Horrobin then went on to point out that the reason why most patients with a rapidly
lethal disease volunteered for a clinical trial, is through altruism, and pointed out
that actually, what these patients want to do is survive and have some hope. He
also pointed out that all the clinical trials open to them, involved the use of
significantly toxic substances or procedures which are likely to do the vast majority
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of patients involved in such trials, more harm than good. He points out that the
reason these clinical trials are large, say more than 100 patients, is that the
expected effect size is very small. This therefore means that most patients entering
such trials have little or no chance of receiving benefit and have a high chance of
harm. He goes on to point out that such large multi centred trials are very costly
and can only be done on patent protected new chemical entities or chemical entities
which have the minimum of 15 years of patent protection left. Therefore he argues
that these approaches are financially driven by large companies who have sufficient
financial muscle in order to fund them.
Horrobin then goes on to say the following:
‘Any scientifically or medically qualified person who develops a lethal cancer rapidly
learns many things. Two of them were especially surprising to me. First, as in my own
case, the usual effects of standard treatments were all-to-often both toxic and of
minimum therapeutic value. Occasionally patients do very well, but the outlook for
most is gloomy. Moreover, the evidence base is near useless as a guide to what is
likely to happen in one’s own case, partly because the exclusion and inclusion criteria
for trials are often so narrowly drawn that most individuals are unlikely to fit them.
Another contributing factor is that effect sizes are so small that the numbers
needed-to-treat to get one durable response may well be over thirty and often even
higher. So, for the individual, treatment is indeed a lottery. In view of the frequently
severe adverse events, usually much more predictable and reliable in their occurrence
than is a therapeutic response, a decision on the patient’s part not to be treated is
not irrational. I learned that few patients are made aware of this fact: that is
unethical.
The second surprising thing that I learned is that, for most cancers, there are many
potential treatments, many of which are not toxic. Contrary to general orthodox
medical opinion, most such potential treatments are neither fringe nor irrational.
They are based on solid biochemical in-vitro work, on reliable work in animals and
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occasionally on a few well documented case histories. But they have not been
adequately tested in well designed trials, and most of them never will be. The reason
for that has nothing to do with their scientific rationale or the strength of the
evidence. It is simply that they are unpatentable or difficult to patent. Without
patent protection, in the present climate, such potential remedies will never be
tested.’
Therefore the informed patient, if their chances are 20 per cent or less, which is most
often the case in late stage recurrent cancers, they look for alternatives which do
not carry the downside of toxicity, if they produce a positive effect that is a bonus,
but at least they do not have a downside. Generally speaking the majority of
oncologists are unsympathetic to these approaches especially in the UK, but are
more open in America. They say that these approaches are unproven, but it is clear
to me that if they were on the other side of the divide like David Horrobin was, then
they might think differently.
In my opinion, it is highly likely that many of these approaches we use which are
unpatentable, such as the use of high dose intravenous vitamin C, might well produce
similar clinical results if trialled in large enough trials as standard chemotherapy is
and is continually trialled in this way. The research evidence therefore for
conventional approaches, is of high quality, because it is driven by a well financed
machine, with good international communication, and there is a continuous research
process going on entirely focused on these patentable treatment approaches.
Current Research Directions
I wish to draw on another article written by David Horrobin (Not in the Genes,
Enthusiasts for genomics have corrupted scientific endeavour and undermined hopes
of medical progress, in comment and analysis, the Guardian 12 February 2003, page
20.) He pointed out in this thought provoking article that triumphalism about
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molecular biology, genomics and the human genome is an increasingly pervasive theme
in biomedical science. You may care to note in what follows as to how often he uses
the word reductionist:
I quote: ‘starting in the 1960’s, molecular biologists and genomic specialists took
over biomedical science. Everything was to be understood completely at the
molecular genomic level. Everything was to be reduced to the genome. Journals and
grant giving bodies came to be dominated by reductionists who were scathing about
the complexity of whole organ, whole animal and especially whole human studies which
were seen as too full of uncontrolled variability to be interpretable. Clinical and
physiological studies lost out and progressively their research communities were
destroyed. Now we have an almost wholly reductionist biomedical community which
repeatedly makes exaggerated claims about how it is going to revolutionise medical
treatment, and which repeatedly fails to achieve anything’.
He then goes on to talk about cancer and makes the following comment:
‘We have made dramatic progress in a very limited range of rare cancers: the
leukaemias, lymphomas and testicular tumours. But even then many of the drugs
used were introduced before 1965. We have simply learnt to use them better. The
idea that genomics is going to make a major contribution to human health in the near
future is laughable, but the tragedy is that whole organism biologists and clinicians
who might have helped unravel the complexities are almost all gone, destroyed by the
reductionists’.
These observations are of major importance to integrated medicine, and to the
systems approaches deployed by many forward thinking integrated doctors (see
later).
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For my own part, I do not deny the importance of genes. I am fascinated by the fact
that we share half our genes with bananas, something which is more apparent to me
in some of my colleagues as opposed to others!
Peer review is what drives the clinical trial and publication process in its currently
largely reductionist framework. The process of having your paper published, is
governed by a process known as peer review. What this amounts to is your colleagues
and often, if you are in a particular field, these colleagues may be close friends of
yours, looking at your paper in an anonymous way, and making appropriate comments
which govern whether the paper will be published or not, as the editor is bound to be
highly influenced by the opinions of the peer reviewers. Often specialised fields in
medicine and indeed all of the sciences are relatively small and the peer reviewer will
almost certainly know who has written the paper, even though the paper is sent to
them anonymously. The stifling effects of the system of peer review has been pointed
out by a range of influential medical thinkers, particularly David Horrobin, and he
originated the thesis that clinical research has declined in its ability to generate
major break throughs, largely in his view due to the stifling effects of peer review. A
recent piece in the British Medical Journal (Little evidence for effectiveness of
scientific peer review, BMJ Vol 326, 1 February 2003, page 241) stated that the
international Cochrane collaboration, which is the gold standard of collation of
medical research material, says that there is little hard evidence that peer review
improves the quality of published medical research. It goes on to say the system has
been in use for at least 200 years and has only recently come under scrutiny with its
assumptions about fairness and objectivity.
The Cochrane collaboration concluded that on the basis of current evidence, the
practice of peer review is based on faith rather than on facts. They went on to say
that not only do peer reviews pander to egos and give researchers licence to knife
each other in the back with impunity and anonymously, but it is also completely
useless at detecting research fraud and lets editors off the hook for publishing poor
quality studies.
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Challenges to the Randomised Control Trial Format
I have watched with great interest over many years, the work of Professor William
Tiller and his group in California. Professor Tiller looked at simple electronic devices
which he called intention imprinted electrical devices. These devices were ‘imprinted’
by imprinters who were trained in meditative techniques. In practice this involves the
imprinter, who is chosen as somebody used to spiritual practice, particularly in the
meditative area. He or she holds the device in their hands, and focuses on specific
intents in their mind, attempting to imprint this intent on the electrical device. In
practice, this only takes a short period of time, 20 minutes to half an hour. He
describes this as a unique human consciousness induced processing procedure.
Intention printed devices and unimprinted devices were studied extensively over a
three year period. The target materials selected for these studies were:
1. Water
2. Liver enzyme — alkaline phosphatase
3. The main cell energy storage molecule ATP
4. Living fruit fly larvae
The imprinted devices produced robust and repeatable effects on all of these
systems which was highly statistically significant (P< 0.001), this is indeed an
extraordinary result (New experimental data revealing an unexpected dimension to
material science and engineering. William A Tiller and Walter E Dibble, Mat Res
Innovat (2001:5:21-34). Also (Towards general experimentation and discovery in
‘conditioned’ laboratory spaces Part 1: Experimental pH-change findings at some
remote sites by W A Tiller et al. 2003 (in press), original copy available from the
author, also; Towards general experimentation and discovery in conditioned
laboratory spaces. Part 2: pH-change experience and 4 remote sites one year later,
W A Tiller et al. 2003, in press, original manuscript available from the author).
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These papers showed a remarkable entanglement process occurring between the
treatment devices and the placebo, and this occurred are vast distances between
the sites, in some instances 2000 miles. This new data shows that human
consciousness, at least under some conditions can strongly influence well designed
target experiments and physical reality. This entanglement is a classical type of
entanglement between laboratories of large or small size. This implies that double
blind studies will not work and that that placebo and treatment in a medical
experiment are mathematically connected in a precise way. This kind of
entanglement, seems to be most marked in any therapeutic discipline which involves
subtle energies, which a large percentage of complementary and alternative medicine
uses. In my view this work, which has been impeccably conducted to the highest
scientific standards, is of huge importance. The degree of ‘conditioning’ of laboratory
space seems to depend on four main factors as elucidated by Professor Tiller, these
are:
a) History of the local space and objects of the local space;
b) Intention imprint and charge from any intention imprinted electrical device;
c) The consciousness and biofield of experimenters or of the people occupying
laboratory space;
d) The level of potentisation of the measurement equipment in the space.
All of these factors are central to the way complementary therapists view their
practices and also is what makes them so different from the way conventional
doctors operate their kind of practice. I would hope that in some quarter this kind of
work may be taken seriously.
Professor Tiller’s work seriously challenges the randomised control trial gold
standard when applied to any complementary medical discipline which involves, in any
way, concepts of subtle energy.
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Vitalism and Subtle Energy
Complementary and alternative medicine is full of ideas about ‘energy’. This is really a
modern way of talking about life force, and was taken seriously by some scientists as
recently as the 20th century but not since. Its origins are probably pre-historic, and
it was generally held to be some kind of subtle substance or force which exists which
is responsible for life. Its principle is often identified with the breath, because clearly
when we are dead we stop breathing. There are various words which describe subtle
energy, for example the Sanskrit word prana, in traditional Chinese medicine the
concept of chi, in acupuncture the meridians are supposed to carry chi flowing around
the meridians in a particular sequence. Illness is thought to occur when blockage
occurs in the flow of chi, and from the point of view of acupuncture, needling around
the areas which might influence this block, will allow the chi to flow again. Samuel
Hahnemann enshrined this notion of subtle energy and homeopathy in the process of
‘dynamization’. He implied that there was some kind of vital force in the non-material
homeopathic remedy.
A whole range of therapeutic systems in CAM use in various ways, this idea of energy.
Electrodermal testing is to some extent a way of measuring this energy, and is the
area which interests me most within all of CAM. This involves placing medications to
be tested in electrical circuits with a patient to determine what is the best choice of
treatment. The science behind subtle energy, in my view is the biggest challenge to
the biomedical model which CAM presents. The biomedical model with its increasingly
rigid structures, such as the ubiquitous use of RCT’s, is ever more hostile to these
ideas. Whilst on the opposite side, from the complementary medicine practitioners,
detailed questions about the nature and function of this subtle energy produces
totally confused ideas with little of it backed by experiment. There is no general
agreement at to how it works and there is seldom any serious attempt to describe
any scientific backing to these energies. There have been a number of attempts to
update the concepts by reference to contemporary physics, and these have been
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successful in probably three groups worldwide. Conventional medical colleagues brush
this off as pseudo science. This is often in my experience a situation where the
accuser has not looked at the science and does not anyway have any of the basic
scientific background in physics and maths in order to understand it. There is an
almost existential terror amongst conventional doctors when confronted by these
ideas and that in my view is what is so interesting about them, because they
potentially open up a huge new world of understanding of the way living systems work.
I myself, have been able to repeat work carried out with Professor Hiroshi Motyama
from Tokyo looking at electrical changes over acupuncture points and have been able
to show that these recordings are remarkably consistent, when looked at using a
statistical technique which looks at similarities as opposed to differences called the
co-efficient of variation. For example, doing a standard blood test like a haemoglobin
with a split sample sent to two different laboratories, the results should have a co-
efficient of variation of 15 per cent or less. If it is significantly less than 15 per cent
or less then this is a repeatable and stable result, inevitably they will not be identical.
The co-efficient of variation we have found on the electrical measurements over
acupuncture points showed co-efficient of variation of an average of 6 per cent. This
is truly a remarkable result (Kenyon JN, Pfeiffer, L, Brenton, M. A statistical
comparison of repeatability in three commonly used bioelectronic devices: curling
photography, segmental electrogram, and the AMI of Motoyama. Acupuncture in
Medicine May 1998, Vol 16 No.1 p 40-42). My friend and long-time scientific colleague
Glen Rein has produced an important experimental study showing the existence of chi
(The use of DC electrodermal potential measurements and healers felt sense to
assess the energetic nature of qi. Syldona, N, Rein, G. The Journal of Alternative
Complementary Medicine Vol 5, No.4, 99 p 329-347). Professor William Tiller’s work
however, stands head and shoulders above any group world wide. Professor Tiller is
emeritus professor of crystallography from Stanford. He has been studying these
areas for nearly 40 years, more or less as a research hobby, but full time since his
retirement. The point about his work and that of Glen Rein and my own work, is that
this is experimental work, within the agreed rules of modern experimental science.
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Professor Tiller’s recent work, mentioned earlier in this paper is best described in his
recent book, ‘Conscious Acts of Creation’ (Conscious Acts of Creation, the
Emergence of a New Physics. William Tiller, Walter Dibble and Michael Cohane, Pavior
Books ISBN: 1-929331-04-5, 2001). One other important area of subtle energy
testing which most of you will be familiar with is so called muscle testing, (applied
kinesiology). This is universally derided by conventional doctors, but it undoubtedly
works, and many complementary practitioners use it.
In conclusion to this section, these subtle energy techniques are particularly
vulnerable to classical entanglement between treatment and placebo groups, as
described earlier in this paper. Therefore, they would not be studied effectively or
honestly using an RCT format. This is exactly what many complementary
practitioners have told their conventional colleagues, but are not being heard. This
plea came out in the recent House of Lords commission on CAM. However, in the
report a great deal of space was given to pedantic doctors of high academic
standing, who said there is absolutely no reason whatsoever in their view, why CAM
should not be testable using a double blind RCT format. It is perfectly clear to me
from reading the report, that these doctors had not even devoted any thought
whatsoever to the suggestions given by the complementary practitioners. There can
be something breathtaking about the arrogance of doctors sometimes. What I have
written here in this section, is good serious science. It is hardly known at all, I could
almost certainly guarantee it would be new to the majority of the readership of this
paper. Looking at medical history, this is the way new changes happen in medicine,
they do not occur in the mainstream, very much on the boundaries. This is the case
with subtle energies. I would hope that some of you may be inclined to look further
with this work and may be it could be researched in an open-minded way, which has
not been my experience to date.
Evidence Based Medicine
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The current international fashion is evidence based medicine. This arose originally in
America, principally as a means of controlling medical costs. It is true that many
American doctors abused their position and did excessive tests and unnecessary
treatments on their patients, and insurance companies were finding it difficult to
pay. They, therefore quite reasonably limited what doctors could do, on the basis of
evidence. The gold standard is defined as the RCT. This has meant an increasingly
tight rein on health spending. What this also means so far as CAM is concerned, as
described earlier in this paper, is that CAM is even less and less likely to receive
official support from the NHS or from private health insurance companies. This is of
some major importance so far as our patients are concerned. Therefore, the debate
in this paper, is not simply an academic exercise, it has real and important
consequences.
The whole thought pattern of evidence based medicine is highly linear. In other words,
we have problem (a) and we have intervention (b) and its statistical chances of
success as determined by RCT’s is x per cent. That is all very well for simple illnesses.
However, the majority of chronic illnesses are complex, for example Chronic Fatigue
Syndrome, cancer, multiple sclerosis to name but a few. It is these complex chronic
diseases which form the majority of patients attending to complementary and
integrated medicine practitioners. These illnesses need a systems approach which in
simple terms essentially means approaching the clinical problem from a number of
points of view all at the same time.
Systems Theory was developed in the 1950’s by physicists as a means of describing
the behaviour of complex systems. It is most famously enshrined in the work of
Geoffrey Chew in the S Matrix theory, known as the Boot Strap Approach. This
developed into systems theory (Capra,F. The turning point science, society and the
rising culture, Flamingo 1982.) In the Systems approach each particular
intervention, may produce a small percentage advantage. In order to detect this
percentage advantage as being statistically significant from an RCT point of view,
one would have to have a clinical trial in which the treatment arm and the placebo
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arm each contained several hundred subjects. This is not feasible practically. I call
this kind of medicine Titanic medicine, in other words I am always looking for
treatment advantage and another few degrees on the rudder in time, means you
don’t hit the iceberg!
However, the vice of evidence based medicine gets ever tighter, and so it is even more
difficult to discuss these ideas with an open minded audience. I would sincerely hope
that our fledgling society could be such a forum where we could discuss these ideas,
but I would not be so rash to suggest that any points or we are making as a society
in this area would have any impact on medicine in general. However, it is better than
nothing to at least be able to discuss these ideas.
David Horrobin ably grasped this problem in a sentence in his guardian piece on
genomics, ‘journals and grant giving bodies came to be dominated by the
reductionists who were scathing about the complexity of whole organ, whole animal
and especially whole human studies, which were seen as too full of uncontrollable
variability to be interpretable’. This in my view is important, because simply turning
away from the complexity of things denies that complexity exists in the first place
which indeed it does. I would suggest therefore that the rigid view of evidence based
medicine is equivalent to burying our head in the sand.
Creativity in Medicine
My experience of creativity is that there has to be a particular level of freedom
present in order for creativity to occur. This was brought home to me forcibly many
years ago, when I had a patient who had lost an arm through an industrial accident.
This man was an exceptionally capable engineer. He took up a hobby of building
working replicas of steam locomotives. When I met him he had just finished modelling
the Royal Scot. I was really interested in what he was doing and asked him if he could
bring his model along to the surgery so that I could look at it. Sure enough, he
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brought it along, and this model was enormous, nearly 3 and a half feet long, and a
shining gleaming working locomotive. Now, he told me something most interesting.
Being a perfectionist, he had made his model to such narrow tolerances, that it
became so tight, that nothing would move. He then said to me that he had had to
take it all to pieces again, make the tolerances less tight in order to give the
mechanical system some freedom, and then at a critical point when the tolerances
had been lessened sufficiently, the model worked perfectly. This I feel is what is
happening in medicine today, in that modern medicine is aiming for perfection, for all
sorts of reasonable and dubious motives, for creating a perfection which probably
does not exist anyway, and is not perfection, only in the minds of doctors and their
devotees of evidence based medicine.
Returning to my original questions, firstly as to why CAM is so popular?
Educated people who are the principal users of such approaches, have antennae
which pick up that things are not quite right. They feel that there maybe something
wrong with cancer treatments which are so potentially harmful and have such low
success rates. So, another approach which doesn’t have these downsides is of
considerable interest to them.
My second question, why is there such a huge chasm between research findings in
CAM, and its use by the general populous?
It would appear to me that we need to have a more creative view of the way we
assess CAM, even if it does mean that the holy grail of randomised control studies is
challenged. Perhaps we ought to face up to the realities of complex illnesses,
rather than reducing them out of existence. This fools nobody.
My third and last question is, what is the most challenging aspect of CAM?
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This undoubtedly is to do with ideas of vitalism and subtle energies. We are at last
seeing some real insights into these areas and this, I think, will prove to be an
increasingly interesting, challenging, and probably vitriolic debate.
I hope that I have interested all of you, made some of you think, and inspired a few.
Thank you for listening.
Dr Julian Kenyon
Paper Presented at the Inaugural Conference of the British Society of Integrated
Medicine
Saturday 1 November 2003
Royal College of Physicians
Regents Park
London
I wish to thank Professor Michael Gearin-Tosh for helping me put this presentation
together.
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